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Intradiscal O2–O3 injections are conventionally used as a minimally invasive treatment for lumbar disc herniation in patients not responding to conservative treatments. The aim of the present study is to report data of long-term imaging follow-up (3 years) of patients treated with intradiscal O2–O3 lumbar chemiodiscolysis. We evaluated the changes of disc volume and the modifications in disc appearance (in terms of disc degeneration) and endplate changes (according to Modic), comparing the results with a control group of patients. Our results showed a stable reduction of the disc herniation volume in patients treated compared with the control group, while we did not find statistically significant differences in terms of disc degeneration and endplate changes (Modic). We concluded that the O2–O3 discolysis, despite leading to a significant shrinkage of the disc herniation, does not involve – in the long term – biomechanical changes of the spine in terms of acceleration of the disc degeneration process in comparison with the natural course.

PURPOSE: The present study aims to demonstrate the advantage of treating the radicular compression with the minimally invasive approach such as the discolysis with Ozone Therapy, rather than the surgical approach that we know has complications such as the spine fail back syndrome. This study shows the experience in Bolivia shows from August 2004 to August 2016. MATERIAL AND METHODS: Were treated 926 patients with radicular compression at cervical, thoracic and lumbar level 569 males and 357 females First were performed intra discal injections, the discolysis, of ozone at 30 mcgr/mL followed by 15 or 20 paravertebral injections at 20 mcgr/mL. RESULTS: Among the 926 patients with radicular compression were observed that sensory and motor dysfunction were completely abolished in 611 patients (66%) improved in 176 patients (19%) and with poor results and the dysfunction remained unchanged in 139 patients 15% some of them underwent surgical treatment. DISCUSSION: The discolysis with Ozone is a minimally invasive approach is atraumatic and safety and with this method avoids complications such as spine fail back syndrome, which in USA statistics are reported in 15% to 20%. CONCLUSION: With the treatment of ozone therapy is possible to obtain excellent and good results in 85 % of the cases. Ozone is a useful alternative the effectiveness using this minimal invasive method can avoid complications like spine fail back syndrome.

PURPOSE: To inform on the characteristics, results and epidemiological data on the treatment of Disc Herniation in Costa Rica. PATIENTS AND METHODS: We evaluated the handling of 1240 patients, with Disc Herniation at Cervical 147 cases (11.85%), Thoracic 1 case (0.09%) and Lumbar 1092 cases (88.06%) levels. They were all treated with Oxygen-Ozone therapy, in an ambulatory form, with a protocol of treatment, initially consistent of three to four sessions of paravertebral intramuscular infiltration (O3: 20 mcgr/mL), followed by a session of “Discolysis” (O3: 38-40ug/mL) technique under sedation and fluoroscopy, followed by four to five complementary sessions of paravertebral intramuscular infiltration of 02-03, in a lapse from three to six weeks. RESULTS: In our casuistry we treated 669 men (54%) and 571women (46%) and deducted that there is an evident predominance in the incidence of lumbar disc hernias with 1092 cases, followed by the cervical disc hernias with 147cases, with a negligible incidence of Thoracic Hernias (1 case 0.09%). DISCUSSION AND CONCLUSION: The results achieved with the O2-O3 Therapy are highly satisfactory; especially with the cervical (84.2%), and we believe that it is due to a less incidence of associated pathologies and a higher conscience of the problem by the patients.

Purpose Evaluate the discal morpho-structural changes as a predictive sign in the clinical outcome after ozone therapy in lumbar disc herniation using the T2–shine through effect in diffusion-weighted imaging (DWI). Method One hundred and fifty-four patients suffering from lumbosciatica (89 men and 65 women; age range, 23–62 years) were included, previous MR study performed with FSE-T2 and T2-fat, SE-T1 and DWI sequences, and were randomly assigned to two groups. Seventy-seven patients (control group) underwent conservative treatment with intraforaminal injection of steroid and anaesthetic. The remaining 77 patients (study group) underwent the same treatment with the addition of oxygen–ozone (O2–O3). During the following six months, a MRI follow-up with the same sequences was performed. An intervertebral disc volumetric analysis (IDVA), DWI signal score and post treatment clinical outcome evaluation were performed for an assessment of hernia reduction. χ2 test, Student's t test and analysis of covariance were used for comparison of variables. Results In the study group, 58 of 77 patients had a successful outcome (responders). In the responders group, DWI T2–shine through effect was present during MRI follow-up and in particular in 53 of 77 patients in six months of follow-up ( p Conclusions T2–shine through effect in DWI is present before morphological disc reduction and moreover could be considered as a predictive sign of response to oxygen–ozone treatment.

To evaluate the discal morpho-structural changes as predictive sign in the clinical outcome after Ozone Therapy in lumbar disc herniation using the T2 shine-through effect in DWI.One hundred and fifty-four patients suffering from lumbosciatica (89 men and 65 women; range 23-62 years) were included in previous MR study performed with FSE-T2 and T2-fat, SE-T1 and DWI sequences and were randomly assigned to two groups. Seventy-seven patients (Control Group) underwent conservative treatment with intraforaminal injection of steroid and anesthetic. The remaining 77 patients (Study Group) underwent the same treatment with the addiction of oxygen-ozone (O2-O3). During the coming 6 months, an MRI follow-up with the same sequences was performed. An intervertebral disc volumetric analysis (IDVA), DWI signal score and post treatment clinical outcome evaluation were performed for an assessment of hernia reduction. χ (2) test, Student's t test and analysis of covariance were used for comparison of variables.In the Study Group, 58 over 77 patients had a successful outcome (Responders). In the Responders group, DWI T2 shine-through effect was present during MRI follow-up and in particular in 53 of 77 patients in the 6 months of follow-up (P 0.05). Moreover, in the same group was present a statistically significant discs' shrinkage in the sixth month of follow-up (P 0.05) as showed by IDVA.T2 shine-through effect in DWI is present before morphological disc reduction and moreover could be considered as a predictive sign of response to oxygen-ozone treatment.

This work presents results of our experience with oxygen-ozone therapy, which we could experiment inside the Italian National Health System through 3 years. A total of 1920 patients were admitted to our evaluation on the basis of unselected enrollment because of lumbosciatic pain. Patients were divided in three groups: (A) Patients with degenerative disc disease and arthropathy: 509 (26.5%), (B) Patients with failed back surgery syndrome (FBSS): 1027 (53.489%), and (C) Patients with pure herniated lumbar disc: 384 (20%).The perceived quality of result makes oxygen-ozone therapy a useful weapon in the hand of the doctors.

An estimated 40% of chronic lumbosacral spinal pain is attributed to the discus intervertebralis. Degenerative changes following loss of hydration of the nucleus pulposus lead to circumferential or radial tears within the annulus fibrosus. Annular tears within the outer annulus stimulate the ingrowth of blood vessels and accompanying nociceptors into the outer and occasionally inner annulus. Sensitization of these nociceptors by various inflammatory repair mechanisms may lead to chronic discogenic pain. The current criterion standard for diagnosing discogenic pain is pressure-controlled provocative discography using strict criteria and at least one negative control level. The strictness of criteria and the adherence to technical detail will allow an acceptable low false positive response rate. The most important determinants are the standardization of pressure stimulus by using a validated pressure monitoring device and avoiding overly high dynamic pressures by the slow injection rate of 0.05 mL/s. A positive discogram requires the reproduction of the patient's typical pain at an intensity of > 6/10 at a pressure of < 15 psi above opening pressure and at a volume less than 3.0 mL. Perhaps the most important and defendable response is the failure to confirm the discus is symptomatic by not meeting this strict criteria. Various interventional treatment strategies for chronic discogenic low back pain unresponsive to conservative care include reduction of inflammation, ablation of intradiscal nociceptors, lowering intranuclear pressure, removal of herniated nucleus, and radiofrequency ablation of the nociceptors. Unfortunately, most of these strategies do not meet the minimal criteria for a positive treatment advice. In particular, single-needle radiofrequency thermocoagulation of the discus is not recommended for patients with discogenic pain (2 B-). Interestingly, a little used procedure, radiofrequency ablation of the ramus communicans, does meet the (2 B+) level for endorsement. There is currently insufficient proof to recommend intradiscal electrothermal therapy (2 B±) and intradiscal biacuplasty (0). It is advised that ozone discolysis, nucleoplasty, and targeted disc decompression should only be performed as part of a study protocol. Future studies should include more strict inclusion criteria.

This paper describes discolysis by intradiscal, periganglionic and periradicular oxygen-ozone (O(2)-O(3)) injection, a minimally invasive percutaneous technique for the treatment of lumbar disk herniation.From June 2000 to December 2006, we performed O(2)-O(3) chemonucleolysis procedures in 2,900 patients affected by lumbar disk herniation. Patients were selected on the basis of clinical, psychological, neurological and neuroradiological criteria. Exclusion criteria were extruded hernia and/or free disc fragments, hyperalgesic-paralysing sciatica and progressive neurological impairment of the affected limb. All percutaneous treatments were performed under computed tomography (CT) guidance. All patients were evaluated after 1 month, and those showing only partial success were scheduled for a second treatment session.Results were evaluated with the modified MacNab classification, the visual analogue scale and the Oswestry Disability Index at 6 and 12 months. Success rates were 75%-80% for soft disc herniation, 70% for multiple-disc herniations and 55% for failed back surgery syndrome. None of the patients suffered early or late neurological or infectious complications.According to our data, minimally invasive percutaneous treatment by intradiscal, periradicular or periganglionic O(2)-O(3) infiltration is a valuable and competitive technique that provides excellent results at low cost and without complications.

A follow-up of 1289 chemonucleolyses performed on 1141 patients and a questionnaire answered by 80% of these patients shows that some conditions hitherto held to be contraindications can be questioned: chemonucleolysis performed in cases of disk herniations with spinal stenosis can produce very good results. A second chemonucleolysis with chymopapain at a later date is possible. In patients who have previously undergone surgery on the same disk, chemonucleolysis offers good chances of improvement in the event of a reherniation.

The role of CT scanning in presurgical planning for stabilisation surgery using metal implants is well-established. However, the advent of new interventional neuroradiology techniques like vertebroplasty, kyphoplasty, ozone discolysis, periganglionic and intraforaminal infiltration of ozone and/or steroids demands more accurate diagnostic assessment of the spine both for surgical planning and during follow-up. In this study we selected 140 candidates for spinal interventional procedures studying them by magnetic resonance scanning (MR) before and after treatment using T2 and T1 fat-saturation (FAT-SAT) sequences after gadolinium administration. T2 and T1-weighted fat-saturation (FAT-SAT) sequences yielded additional information with respect to standard MR investigation of the spine, improving clinical classification and accurate recruitment of surgical candidates. Additional information obtained during follow-up after surgery proved essential in planning the most appropriate maintenance therapy for these patients.

Background: Treatment of low back ache due to prolapsed intervertebral disc is still controversial. Several conservative modalities are available with varied results. Surgical discectomy may lead to failed back syndrome due to change in vertebral column anatomy and its mechanics. To prevent it, conservative means are better and Ozone discolysis is one of the nonsurgical methods. The indications and effectiveness of this condition is not well defined. The present study was done to correlate the clinical outcome of this technique.Methods: This was a prospective study conducted on 67 patients presenting with symptoms of back pain with arid without radicular symptoms. X ray and MRI were done in all cases. Then intradiscal ozone gas was given at one level from a specialized machine under C arm guidance. For evaluation Oswestry disability index and Macnab scoring system was used. Post injection patients were evaluated at 2, 6 weeks and 6 months.Results: Sixty seven patients with mean age of 47.7 years were followed up for 7.8 months. Low back pain was the commonest symptom and SLR was positive in 5.36%. The modified Macnab scoring with good and fair score improved from 16% to 89% and Oswestry disability index with minimal and moderate disability improved from 41% to 91% at end of 6 months. Seven patients had relapse of pain due to repeat disc prolapse. Conclusions: Ozone discloses is better modality of treatment for low back pain with disc bulge and early disc prolapsed.

Findings in a two- to four-year followup of 231 patients who have undergone outpatient chemonucleolysis are reported. Successful outcomes were determined in 88% of cases by the respondents themselves, and in 67% by an independent reviewer. Concerns of outpatient conduct of chemonucleolysis are discussed, noting that all instances of intraoperative complications were successfully managed, including two cases of anaphylaxis.

Research in spine surgery has proposed new soft and less invasive techniques. These are the results of our experience with oxygen-ozone therapy, which we could experiment within the Italian National Health System over 3 years. A total of 1,920 patients were admitted on the basis of unselected enrolment because of lumbosciatic pain. Patients were divided into three groups: (A) Patients with degenerative disc disease and arthropathy: 509 (26.5%), (B) Patients with failed back surgery syndrome (FBSS): 1,027 (53.489%), and (C) Patients with pure herniated lumbar disc: 384 (20%). The rationale of the treatment for all these different pathologies we have taken into consideration is the biochemical mechanism by which they can engender pain and dysfunction. Treatment for group A: paravertebral injection and phleboclysis (two cycles of 6 sessions, one each 3 days) +endoscopic neurolysis. Treatment for group B: paravertebral injection and phleboclysis (two cycles of 6 sessions, one each 3 days) + endoscopic neurolysis with intradiscal procedure (named percutaneous peridurodiscolysis). Treatment for group C: paravertebral injection (two cycles of 6 sessions, one each 3 days) + percutaneous discolysis.

Objetivo: Estudio retrospectivo para evaluar la efectividad y la seguridad del uso de ozono para la discólisis en cuadros de ciática por hernia discal contenida. Material y método: Se incluyó en el estudio a 100 pacientes con clínica de lumbociática con dolor intenso, escala visual analógica (EVA) > 6, de más de 3 meses de duración, que no respondieron al tratamiento de analgésicos y corticoides, por vía sistémica, durante un período mínimo de 1 mes, con signos de dolor radicular e irradiación al dermatoma afectado. Los criterios radiológicos de inclusión fueron: evidencia en la resonancia magnética (RM) de hernia discal contenida. El tratamiento aplicado fue: primera sesión, administración epidural de 10 ml de ozono a 30 μg/ml, triamcinolona 4 mg y 5 ml de bupivacaína al 0,25%, más administración paravertebral 10 ml de O3 a 30 μg/ml, triamcinolona 4 mg y 5 ml de bupivacaína al 0,25% en el lado afectado. Segunda sesión, entre 7 y 10 días de la primera, el mismo tratamiento. Segunda sesión, administración intradiscal de 10-20 ml de O3 a 50 μg/ml más antibioterapia profiláctica. La eficacia analgésica se valoró, a: 1, 3, 6, 12 y 24 meses, mediante EVA y valoración radiológica con RM a los 3, 12 y 24 meses. Se consideraron los resultados: a) excelente: cuando: no hay síntomas, y hay una completa incorporación al trabajo y la actividad deportiva. La EVA descendió > 70%; b) bueno: cuando el paciente presenta dolores ocasionales de espalda o ciática, con completa incorporación al trabajo, usan ocasionalmente analgésicos y hay un descenso de la EVA > 40%, y c) malo: insuficiente mejoría de síntomas, toma diaria de medicamentos, limitaciones en la actividad física, cambio de trabajo y descenso de la EVA < 40% sobre el previo. Se consideró significativo una p < 0,05. Resultados: De los 100 pacientes, 91 pacientes pudieron ser valorados a los 24 meses y de estos 52 fueron varones y 39 fueron mujeres. La edad de los pacientes estuvo entre 26 y 77 años con una media de 52 ± 7. Los niveles afectados, por orden de frecuencia, fueron L4-L5 (49%), L5-S1 (41%), L3-L4 (9%) y otros niveles (11%). Tuvieron un resultado excelente en el tiempo: 1 mes, el 95,6% de los pacientes; 3 meses, el 91,3%; 6 meses, el 90,7%; 12 meses, el 87,7%; 2 y 24 meses, el 81,1%. La RM mostró una reducción significativa del volumen herniario en el 79% de los pacientes. Requirieron una segunda discólisis 5 pacientes, que fueron excluidos del estudio. Tuvimos una discitis y 11 casos de cefalea pospunción (todos en pacientes con discólisis de L5-S1) y 4 con dolor lumbar que requirió tratamiento analgésico. El 32% de los pacientes tomaba paracetamol de forma irregular por dolor lumbar. Los pacientes que requerían otro tipo de medicación fueron retirados del estudio. Conclusiones: La administración de ozono intradiscal con el protocolo descrito consiguió un inicio temprano de la reducción del dolor, que se mantuvo durante más de 2 años, así como una reducción sostenida del tamaño de la hernia producida por el ozono. Objective: We performed a retrospective study to evaluate the safety and effectiveness of ozone discolysis in sciatica due to a contained herniated disc. Material and method: This study included 100 patients with symptoms of intense lumbosciatic pain, visual analog scale (VAS) > 6 and onset more than 3 months previously, who were unresponsive to analgesics and systemic corticosteroids for a minimum period of 1 month and who showed signs of radicular pain and radiation to the affected dermatome. The radiological inclusion criteria consisted of magnetic resonance imaging (MRI) evidence of a contained herniated disc. The treatment applied consisted of the following: a first session with epidural administration of 10 ml of ozone at 30 μg/ml, 4 mg of triamcinolone and 5 ml of bupivacaine 0.25% plus paravertebral administration of 10 ml of O3 at 30 μg/ml, 4 mg of triamcinolone and 5 ml bupivacaine 0.25% on the affected side; a second session between 7 and 10 days after the first, consisting of the same treatment; and a third session with intradiscal administration of 10-20 ml of O3 at 50 μg/ml plus prophylactic antibiotic therapy. Analgesic efficacy was evaluated at 1, 3, 6, 12 and 24 months through VAS and radiological evaluation with MRI at 3, 12 and 24 months. A result was considered: a) excellent when the patient was asymptomatic and able to fully return to work and resume physical exercise and VAS decreased > 70%; b) good when the patient had occasional back or sciatic pain, with complete return to work, occasional use of analgesics and VAS decreased > 40%, and c) poor when there was insufficient symptom improvement, daily medication intake, limitation of physical activity, change of work and VAS decreased by > 40%. P values of < 0.05 were considered signifi cant. Results: Of the 100 patients, 91 could be evaluated at 24 months (52 men and 39 women). Age ranged from 26 to 77 years with a mean age of 52±7 years. By order of frequency, the vertebrae affected were L4-L5 (49%), L5-S1 (41%), L3-L4 (9%), other vertebrae (11%). By month, an excellent result was obtained in the following percentages of patients: 1 month 95.6%; 3 months 91.3%; 6 months 90.7%; 12 months 87.7%; 2 and 24 months 81.1%. MRI showed a significant reduction in hernia volume in 79% of the patients. A second discolysis was required by five patients who were excluded from the study. There was one case of discitis and 11 cases of postpuncture headache (all in patients with L5-S1 discolysis) and four cases of lumbar pain requiring analgesic treatment. Thirty-two percent of the patients took paracetamol irregularly for lumbar pain. Patients requiring other types of medication were withdrawn from the study. Conclusions: Intradiscal ozone administration in the protocol described achieved early onset of pain reduction, which was maintained for more than 2 years, as well as a sustained reduction in hernia size produced by ozone.

Objetivo: Estudio prospectivo y comparativo que compara la eficacia de la administración intradiscal de ozono asociada a radiofrecuencia pulsada de la raíz lumbar comprometida con cada una de estas 2 técnicas, de forma aislada, en el tratamiento del dolor radicular secundario a hernia discal. Material y método: Se incluyó en el estudio a 30 pacientes con clínica de dolor lumbar severo, escala visual analógica (EVA) > 6, de más de 3 meses de duración, resistente al tratamiento conservador (medicación oral y fármacos epidurales), con signos de afectación radicular con o sin parestesia e hipoestesia y con distribución correspondiente al dermatoma afectado. Los criterios radiológicos de inclusión fueron: evidencia en la resonancia magnética (RM) de hernia discal contenida con o sin degeneración discal. Los pacientes se distribuyeron aleatoriamente en 3 grupos: grupo A (5-15 ml de ozono intradiscal a 27 mg/ml de concentración y radiofrecuencia pulsada del ganglio de la raíz dorsal correspondiente); grupo B (5-15 ml de ozono intradiscal a 27 mg/ml de concentración) y grupo C (radiofrecuencia pulsada del ganglio de la raíz dorsal al nivel comprometido). La eficacia analgésica se valoró a los 15 días, al mes, y a los 3 y 6 meses de la técnica, mediante EVA y se llevó a cabo una valoración radiológica con RM a los 3 meses. El estudio estadístico se realizó mediante el programa SPSS 14.0 para Windows. Se consideró significativa una p < 0,05. Resultados: Los niveles afectados, por orden de frecuencia, fueron L4-L5 (16/53,3%), L5-S1 (10/33,3%) y L3-L4 (4/13,33%). El volumen medio de ozono administrado fue, en el grupo A, 8 ± 2,5 ml, y en el B, 6,5 ± 2,4 ml. El 90% de los pacientes del grupo A presentaron mejoría significativa (p < 0,05) en todas las revisiones, en el 80% de los pacientes del grupo B la mejoría se produjo más tardíamente, pero se mantuvo a los 6 meses de la técnica, y en el 90% de los pacientes del C, la mejoría se inició de forma temprana, pero su duración fue significativamente más corta que la de los otros 2 grupos. La RM mostró una reducción significativa del volumen herniario en los grupos A y B (65 y 70%, respectivamente). No se observó ningún tipo de complicación asociada a las técnicas. Conclusiones: La radiofrecuencia pulsada, de la raíz afectada, mejoró los resultados de la administración de ozono intradiscal, con un inicio precoz de la reducción del dolor, posteriormente mantenida por la reducción tardía del tamaño de la hernia producida por el ozono. Objective: We performed a prospective, comparative study that evaluated the effectiveness of intradiscal ozone administration associated with pulsed radiofrequency of the compromised lumbar root versus the isolated use of each of these two techniques in the management of radicular pain secondary to a herniated disc. Materials and method: The study included 30 patients with severe back pain, visual analog scale (VAS) > 6 and onset more than 3 months previously, who were resistant to conservative treatment (oral medication and epidural drugs) and showed signs of radicular involvement with or without paresthesia and hypoesthesia in the region of the affected dermatomes. The radiological inclusion criteria were magnetic resonance imaging (MRI) evidence of a contained herniated disc with or without disc degeneration. The patients were randomly distributed into three groups: group A (5-15 ml intradiscal ozone concentration at 27 mg/ml and pulsed radiofrequency of the compromised dorsal root ganglia); group B (5-15 ml of intradiscal ozone concentration at 27mg/ml) and group C (pulsed radiofrequency of the dorsal root ganglia at the level of the hernia). Analgesic efficacy was assessed at 15 days, 1 month, 3 months and 6 months of the technique, using the VAS. Radiological assessment with MRI was performed after 3 months. The statistical analysis was conducted using SPSS 14.0 for Windows. Values of P < 0.05 were considered significant. Results: the levels affected, in order of frequency, were L4-L5 (16/53.3%), L5-S1 (10/33.3%) and L3-L4 (4/13.33%). The mean amount of ozone administered was 8 ± 2.5 ml in group A and 6.5 ± 2.4 ml in group B. In group A, 90% of the patients showed significant improvement (p < 0.05) in all follow-up evaluations. In 80% of the patients in group B, improvement occurred later, but was maintained at 6 months after the technique. In group C, 90% of the patients showed improvement at an early stage, but its duration was significantly shorter than in the other two groups. MRI showed a significant reduction in hernia volume in groups A and B (65% and 70% respectively). No complications associated with the techniques were observed. Conclusions: Pulsed radiofrequency of the affected root improved the effectiveness of intradiscal ozone administration, with early onset of pain reduction, which was subsequently maintained by the late ozone-induced reduction in hernia size.

Disc herniation with radiculopathy and chronic discogenic pain are the result of degenerative processes. Treatment approach in face of this problem has largely been debated in the last years. A number of reviews on surgical treatments in the ‘80s and ‘90s have been published and various new techniques have been introduced among which ozone discolysis is one non-invasive intradiscal treatment method. In a 3-year follow-up period we have investigated the different outcomes of 150 patients who received microdiscectomy and 150 patients who received intradiscal ozone injection. In this series results are in favour of discolysis for contained disc herniations and of microdiscectomy for large migrated fragments with pain so severe that open surgery was obligatory. Apart from this, our results with the two techniques are equivalent also concerning mild neurological motor deficits.

✓ Of 410 patients with refractory herniated lumbar disc disease treated with intradiscal collagenase, 82 (20%) did not respond to enzyme treatment and subsequently underwent surgery. Failure to improve in 6 to 8 weeks was the predominant cause for surgical intervention (53 patients). Increased pain (18 patients), progressing neurological deficit (10 patients), and disc-space infection (one patient) were the other indications for surgery. At surgery, extrusions and/or sequestrations were found in 46 patients, undigested protrusions in 16 patients, and other causes of treatment failure in 14 patients. Six patients had normal findings. There was no evidence of adverse enzyme activity on the surrounding structures. Surgical results showed an overall success rate of 87%, and did not appear to be compromised by the previous enzyme therapy.

Chymopapain chemonucleolysis was performed on 100 patients with primary lumbar intervertebral disc disease. The results were compared with those of 174 patients who underwent laminotomy, foraminotomy, and discectomy. Primary lumbar intervertebral disc disease was arbitrarily divided into degenerative, complex, previous surgical, and simple disc syndromes. No difference was seen between chemonucleolysis and surgery in the first three divisions; between 55 percent and 60 per cent of patients responded successfully to treatment. In the simple disc division 89 per cent of the surgical and 60 per cent of the chemonucleolysis patients had successful results.

This study reports a series of 52 patients with herniated discs, selected as refractory to conservative therapy, who were treated under an experimental protocol with the enzyme collagenase (Nucleolysin®) instilled into the disc percutaneously. A 78% success rate was achieved in those patients receiving a dose of 600 units. There were no systemic or local toxic effects. The patients were followed for up to two years with only one recurrence. Failures appeared to be associated with disc extrusion.

Premedication with H1 and H2 blockers as well as cortisone to reduce or prevent allergic reactions should be an integral part of the overall treatment. The facilities for immediate treatment of anaphylactic reactions including cardiopulmonary resuscitation must be readily available. Our haemodynamic measurements allow us to give a negative answer to the question--so far not investigated in man--whether the use of chymopapain or of its fragments leads to constant cardiocirculatory effective reactions in the early phase. Our experiences collected so far favour catheter peridural anaesthesia as the method of choice in chemonucleolyses.

The indications for operative treatment of lumbar disc herniations are outlined and the advantages, short-comings and temptations of discolysis, micro-operation and large approach discussed. The following indication scheme is proposed: Discolysis: Non-displaced disc herniation without other major causative pathology; Micro-operation: Displaced disc herniation; non-displaced disc herniation with monosegmental additional causative factors; Large approach: Multiple disc herniations with suspected displacement and multisegmental additional pathologies.

Chymopapain is a substance isolated from the latex of the fruit of the tropical plant Carica Papaya. This substance was first isolated in 1941 by Jensen and Ball.

An analysis is given of a series of 25 patients suffering from lumboischialgic pain of different causes, which have been treated by discolysis. Literature reports are taken into consideration. As a result of analysis, the following statements seem justified: In no kind of lumbar disc prolapse are the results of discolysis superior to those of modern operative treatment. Discolysis results are indisputably worse in cases with the usual operative indication, which consists of neurological deficit and large disc prolapse. Favourable results by discolysis can be obtained in cases with disc protrusion or small prolapse, but these cases can mostly be cured also by consequent conservative treatment. Contraindications are marked neurological deficit, demonstration of a large disc prolapse by contrast methods, Verbiest's stenosis of the lumbar spinal canal, low back pain and ischialgia without possible proof of a disc protrusion, cases with low back pain as the main or only feature, spondylolisthesis. Disc prolapse recurrences after discolysis often occur about one month afterwards. Structural instability at this stage is likely. Therefore, as with postoperative treatment, it is advisable to avoid major physical stress for the first weeks after discolysis. Major complications after discolysis are possible, and have occurred. Because discolysis offers no real advantages but some shortcomings compared to conservative treatment for disc protrusions, and to operative treatment in real disc prolapses, its justification seems more than questionable.

The removal of epiretinal membranes and associated vitrectomy remains a hazardous undertaking even for the highly skilled surgeon equipped with advanced microinstrumentation. The use of a highly purified bacterial collagenase during vitrectomy represents a novel method of facilitating the removal of these dense fibrous membranes.1,2 Bacterial collagenase has been used clinically for debridement of decubitus ulcers3 and dermal burns.4 A highly purified form of the enzyme has been used for intravertebral discolysis, both experimentally and clinically.5 Animal toxicity studies, using electron microscopy and electroretinography, have shown no adverse effects on retinal components when the enzyme is intraocularly administered and allowed to incubate before its removal by the standard irrigation/aspiration process of vitrectomy.1

Recent clinical evidence suggests that papain and chymopapain may share common allergenicity. Patients that become sensitized to papain may subsequently experience an allergic reaction when they are exposed to chymopapain. This study demonstrates a cross antigenicity between the proteolytic enzyme preparations papain and chymopapain. Serum samples from six patients who demonstrated 4+ skin reactions to papain also revealed positive RAST ratios to both papain and chymopapain. In addition, serum samples from 12 clinically nonreactive patients who had discolysis with chymopapain demonstrated positive RAST results to papain as well as to chymopapain.

Patient selection for chemonucleolysis with chymopapain is based on clinical symptoms, and CT scan is performed to exclude cases in which intradiscal therapy is contraindicated. Discography has been advocated during the intraoperative period, in order to detect contraindications for chemonucleolysis and communication between the discal space and the subarachnoid space. However, nowadays this no longer seems necessary in chemonucleolysis, for many reasons, including the following: 1) The interaction between contrast medium and chymopapain can result in inhibition of enzyme action [2, 3] 2) Moreover, in animal studies [5, 6] and as regards toxicity, there were more neurological complications as a result of the combination of contrast medium and chymopapain than with the solution alone injected into the subarachnoid space [7] 3) The interpretation of discograms may be hampered by unrecognized artifacts [4] and discography has no value in selection for discolysis [15, 16]

Fifty-four patients with proven lumbar disc displacement were treated by intradiscal injection of collagenase (Nucleolysin) between April 1981 and January 1984. Follow-up by history and physical examination, phone survey, and/or mail survey shows 72% success rate (excellent, good, and fair) and 28% poor or unsuccessful results. No patient was made worse by the treatment. Success rate was greater in patients older than the age of 50 years, male patients, and patients with pain complaints of longer than 4 months' duration. The presence of a list and/or crossed straight leg raising and/or straight leg raising positive less than 30 degrees was associated with a poor prognosis. Discography prior to collagenase injection did not compromise the outcome of treatment. Postinjection changes in the CT scan correlated with a satisfactory outcome of treatment. Findings at surgery in patients who failed to obtain relief following collagenase injection did not show a specific deleterious effect of the enzyme, nor were the expected results from surgery compromised by a previous unsuccessful intradiscal collagenase injection.

Operations by means of endoscopy are nowadays being widely used as they have advantages, not least the minimal trauma they exert. The use of laser-surgery in urological, gynaecological and bronchial procedures has already become a routine procedure. In orthopaedic operations, such as for example meniscectomy or synovectomy, arthroscopic techniques have found an ever increasing use. Also in a spinal surgery, as well as in the operative treatment of a disc pro-Lapse, microsurgical techniques as well as chemonucleolyses are progressively used. The aim of aur experimental investigations was to determine the effect of laser-operations on joints and intervertebral discs. This was done on tissue of corpses by means of exact infra-red thermographic measurements and histological examination of the tissues treated. Initially we investigated the possible means of employment as well as the suitybility of a CO2-laser and a Neodym-Yag-laser (wavelength 1064 nm) for the treatment of disc-tissue, menisci, and synovial tissue. Following this we developed the application techniques and suitable instruments for the planned operations. Special attention was paid to temperature changes that occured. These were varied and optimized with regard to distance as well as timing, depending on the parameters of the instruments used. In our study we focused on the endoscopic treatment of meniscal and synovial tissue of the knee joint, as well as the so-called “nucleus pulposus vaporization”.

✓ The authors studied five rhesus monkeys for the effects of annulotomy, with or without the addition of a bacterially-derived collagenase into the nuclear-evacuated centrum of lumbar intervertebral discs. The animals were sacrificed from 3 weeks to 21 months after the single or staged double procedures. The earliest radiographic changes were loss of height of the interspace at 7 days, erosion of the vertebral body margins at 3 weeks, malalignment at 6 weeks, osteophytic formation at 3½ months, sclerosis of vertebral body surfaces at 9½ months, and fusion of adjacent vertebral bodies at 13½ months. Pathological changes included early loss of disc convexity, focal new bone formation, osteophytic new growth, through-and-through bone formation, irregular cystification, and disc replacement by hyaline fibrous tissue. Changes were reminiscent of those seen in humans with naturally acquired disc disease or aging of the disc. Injuries were produced in a tissue that probably has a limited scope of variation in reaction to insult.